Optometric Billing-Some Coding Tips, OCT, GDX, Fundus Photos, ETC

Optometric Billing-Billing for an Exam on the Same Day as a Surgical Procedure Such as Dry Eyes or Epilation

It has always been my opinion that in order to bill for an exam on the same day as providing a surgical procedure, such as dry eyes, that one would have to have notated evidence that the examination portion of the encounter was not in fact related to the surgical procedure.  It turns out that after some further research into my coding guidelines this is not just my opinion, it is fact. Let's take a look at how this should be handled.

IE: The patient came into the office for a routine exam or yearly check-up and at that time it was decided that the patient qualified for punctal plugs or epilation. (The plugs would be rare in this instance as it is now necessary to try every other treatment possible BEFORE proceeding with inserting the plugs). 

So, in the example above, the physician would note that "the patient was in for a yearly check up and during the course of exam the patient described to the physician that though the drops he has been using for his dry eye syndrome help somewhat, they are still relatively ineffective at times and he would like to know if there is anything else he could try. At this time the physician offers the option of punctal plugs as they have been shown to be a very effective, though minimally invasive, method of treating the patient's condition. "

If  the condition above, or any other combination of supporting evidence, is present you now have a justifiable basis for billing the insurance company for 1) A comprehensive examination 2) Punctal Plugs. The example above would be billed in a manner similar to the following:

1) 92014-25 (25 modifier means the exam is a separate service from the actual plugs themselves)

2) 68761 (one plug in either eye) or 68761-50 (1 plug in both eyes) or 68761-51 (2 plugs in the same eye) or better still 68761 E1 (E1 meaning it was the upper left lacrimal duct E3 would be upper right and E2E4 are lower left and right respectively). SEE BELOW 

If the condition in the above example is not met, by no means should you bill an insurance company for an exam AND a surgical procedure.At this point, it is understood that the procedure for plugs or epilation etc. includes any examination that need be done. Furthermore,  UNLESS a patient comes into the office for an exam during the 10 DAYS subsequent to the punctal plug procedure for something UNRELATED to the previous procedure you cannot bill the patient's insurance for any further items. In this case, you would bill the proper examination procedure code, followed with a -24 modifier (unrelated E/M procedure during post-op period) SEE BELOW

CLICK HERE TO VIEW THE OFFICIAL MEDICARE COVERAGE INFORMATION FOR BILLING PUNCTAL PLUGS.

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Optometric Billing-Billing For Punctal Plugs

This was burried in our internal notes and is article written by  John Rumpakis, O.D., M.B.A., Clinical Coding Editor. You can find the original text for this article by clicking here.

"Signs and symptoms of dry eye syndrome are often discovered during a comprehensive exam. When further testing is indicated, this may be best done as a follow-up evaluation. This evaluation for dry eye syndrome most likely involves several examination techniques and ancillary tests. These tests, which do not have separate procedure codes, include:

• Patient history (dry eye surveys, symptoms, circumstances, etc.) 

• Tear film break-up time (TFBUT) • Schirmer testing (I&II)  

• Cotton thread or phenol red thread testing 

• Sodium fluorescein, lissamine green and/or rose bengal staining  

• Tear prism evaluation  

• Evaluation of lid wiper epitheliopathy

• Biomicroscopy and examination of ocular surface and lid margins

These tests help you formulate the diagnosis. The appropriate diagnosis code is usually dry eye syndrome (375.15) or keratitis sicca (370.33). Sjögren’s syndrome/keratoconjunctivitis sicca (710.2) is also a possibility, although you should be familiar with your carrier’s requirements prior to initiating any therapy.

In general, before contemplating either surgical or prescriptive treatment, you should have a well documented record of palliative therapy with an artificial tear protocol. The failure of the artificial tear treatment is what provides the medical necessity to proceed to more invasive treatment.

Once you’ve made the diagnosis of dry eye and formalized a treatment plan, several subsequent visits are typically necessary to evaluate the treatment plan. Both the diagnostic and treatment visits are billed using the appropriate office visit codes only. Keep in mind that if you perform the diagnostic examination on the same date as the comprehensive exam, it is not billable as a separate/distinct visit in addition to the comprehensive examination. Follow-up visits to assess the effectiveness of treatment, to alter or to add to the treatment plan are billed using 99212, 99213 or 92012. 

If you decide the patient requires punctal plugs, the billing is the same for temporary diagnostic plugs and permanent plugs. The supply of the punctal plugs is typically included in the insertion code. The insertion procedure is billed per plug in one of two ways. Here is the first method: 

• One plug: 68761  

• Two plugs, different eyes: 68761-50 (billed at 200% of one plug) 

• Two plugs, same eye: 68761-51 (billed at 200% of one plug) 

• Three plugs: 68761-50 (billed at 200% of one plug) and 68761-51 (billed at 100% of one plug) 

 • Four plugs: 68761-50 (billed at 200% of one plug) and 68761-50-51 (billed at 200% of one plug) 

The “multiple surgery rule” applies, so the payment is typically 100% for first plug, 50% for the second plug, and 25% for each of the third and fourth plug. The -50 modifier indicates a bilateral procedure on the same eye and the -51 modifier indicates multiple procedures on the same eye. See Appendix A in your CPT book for further details. 

The second method for billing punctal occlusion is adding the E modifiers to the surgical code to designate which puncta are being occluded. Bill for each plug on a separate line using the appropriate E modifier: 

• E1: upper left  

• E2: lower left  

• E3: upper right 

 • E4: lower right 

The global period for punctal occlusion is 10 days. So, if a patient returns within that period for a follow-up visit related to the punctal occlusion, then that visit is included in the insertion fee. However, if a patient returns for an unrelated problem, then that office visit must be billed using a -24 modifier (unrelated evaluation and management during a postoperative period) in order for you to be compensated for that encounter. "

We would like to thank Dr. Rumpakis for his continued contributions to Medical Coding. His work has proved to be very valuable to our cause as well as many OD's around the country.

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